Too Much Prevention: What Not Too Much Prevention: What Not to Do in the Primary Care Setting to Do in the Primary Care Setting

Agency for Healthcare Research and QualityAgency for Healthcare Research and Quality

Bethesda, MD September 15, 2009Bethesda, MD September 15, 2009

Shannon Brownlee, MSShannon Brownlee, MS

Senior Research Fellow, New America FoundationSenior Research Fellow, New America Foundation

Author: Author: Overtreated: Why Too Much Medicine Is Making Us Overtreated: Why Too Much Medicine Is Making Us Sicker and PoorerSicker and Poorer

brownlee@newamerica.netbrownlee@newamerica.net

DISCLAIMERDISCLAIMER

• No financial conflicts of interest to declareNo financial conflicts of interest to declare

Source: CBO

Source: CBO

Source: CBO

Source: CBO

Busting state budgetsBusting state budgets

The Solution? The Solution?

70% of Americans consider 70% of Americans consider PREVENTIONPREVENTION the most important the most important

aspect of health care reform (other aspect of health care reform (other than covering everybody)than covering everybody)

  

  

The Solution? Prevention!The Solution? Prevention!

Max Baucus: Max Baucus: “Reforming our system to focus on “Reforming our system to focus on prevention will drive down costs and produce prevention will drive down costs and produce better health outcomes.”better health outcomes.”

Ron Wyden: Ron Wyden: “Prevention and wellness come first. “Prevention and wellness come first. These are cost-effective solutions that will These are cost-effective solutions that will improve quality of life, prevent disease, and improve quality of life, prevent disease, and

most important most important save livessave lives.”.”

Kay Granger (R-TX): Kay Granger (R-TX): "An investment of just $10 per "An investment of just $10 per person per year could save this country more person per year could save this country more than $16 billion annually within five years.” than $16 billion annually within five years.”

  

  

PREVENTION = SCREENING (Catch it early) PREVENTION = SCREENING (Catch it early)

• Heart disease – cholesterol testHeart disease – cholesterol test• Heart disease – 64-slice CT scanHeart disease – 64-slice CT scan• Lung cancer – CT scanLung cancer – CT scan• Prostate cancer – PSA testProstate cancer – PSA test• Colon cancer – colonoscopyColon cancer – colonoscopy• Osteoporosis – Dexa scanOsteoporosis – Dexa scan• Carotid artery disease – DopplerCarotid artery disease – Doppler• Ovarian cancer – Ca125 testOvarian cancer – Ca125 test• Breast cancer – mammograms and BRCA testBreast cancer – mammograms and BRCA test• COPD – spirometryCOPD – spirometry

Prevention = Surgery (head it Prevention = Surgery (head it off at the pass)off at the pass)

• Silent gall stonesSilent gall stones • Chronic stable angina Chronic stable angina • Carotid artery stenosis Carotid artery stenosis • Herniated discHerniated disc • Early prostate cancer Early prostate cancer • Enlarged prostate (BPH) Enlarged prostate (BPH)

Dr. Michael LeFevreDr. Michael LeFevre

• USPSTFUSPSTF

• Evidence for screening testsEvidence for screening tests

• Pressures on PhysiciansPressures on Physicians

Preference-Sensitive Care Preference-Sensitive Care

• Involves tradeoffs -- more than one treatment Involves tradeoffs -- more than one treatment exists; not getting treated at all is an option; exists; not getting treated at all is an option; and the outcomes are different depending and the outcomes are different depending upon the patient’s choiceupon the patient’s choice

• Decisions should be based on the patient’s Decisions should be based on the patient’s own preferencesown preferences

• But provider opinion (preference) But provider opinion (preference) often determines which treatment is often determines which treatment is usedused

TURP for BPH per 1,000 male Medicare TURP for BPH per 1,000 male Medicare enrollees (2005)enrollees (2005)

0.50.5

1.51.5

2.52.5

3.53.5

4.54.5

5.55.5

6.56.5

7.57.5

8.58.5

9.59.5Ratio toRatio to

HRR HRR lowest lowestProvidence, RIProvidence, RI 2.672.67Lubbock, TXLubbock, TX 2.632.63Bismarck, NDBismarck, ND 2.462.46Washington, DCWashington, DC 2.072.07Burlington, VTBurlington, VT 2.052.05Hartford, CTHartford, CT 1.921.92St. Paul, MNSt. Paul, MN 1.891.89Worcester, MAWorcester, MA 1.891.89Baltimore, MDBaltimore, MD 1.851.85Minneapolis, MNMinneapolis, MN 1.791.79White Plains, NYWhite Plains, NY 1.741.74Bangor, MEBangor, ME 1.741.74Manhattan, NYManhattan, NY 1.741.74Portland, MEPortland, ME 1.571.57Seattle, WASeattle, WA 1.481.48Salt Lake City, UTSalt Lake City, UT 1.441.44Casper, WYCasper, WY 1.431.43Wilmington, DEWilmington, DE 1.361.36Richmond, VARichmond, VA 1.171.17Baton Rouge, LABaton Rouge, LA 1.031.03Lebanon, NHLebanon, NH 1.001.00

CABG surgery per 1,000 Medicare enrollees CABG surgery per 1,000 Medicare enrollees (2005)(2005)

2.02.0

4.04.0

6.06.0

8.08.0

10.010.0

Ratio toRatio toHRR HRR lowest lowest

Lubbock, TXLubbock, TX 2.592.59Baton Rouge, LABaton Rouge, LA 2.342.34Baltimore, MDBaltimore, MD 1.881.88

Providence, RIProvidence, RI 1.161.16Worcester, MAWorcester, MA 1.151.15Seattle, WASeattle, WA 1.141.14

Percutaneous coronary intervention per Percutaneous coronary intervention per 1,000 Medicare enrollees (2005)1,000 Medicare enrollees (2005)

2.02.0

10.010.0

18.018.0

26.026.0

34.034.0

42.042.0

Ratio toRatio toHRR HRR lowest lowest

Lubbock, TXLubbock, TX 2.592.59Worcester, MAWorcester, MA 1.861.86Baltimore, MDBaltimore, MD 1.771.77

Providence, RIProvidence, RI 1.211.21Seattle, WASeattle, WA 1.091.09Baton Rouge, LABaton Rouge, LA 1.051.05

Back surgery per 1,000 Medicare enrollees Back surgery per 1,000 Medicare enrollees (2005)(2005)

1.01.0

3.03.0

5.05.0

7.07.0

9.09.0

11.011.0Ratio toRatio to

HRR HRR lowest lowestCasper, WYCasper, WY 5.415.41Lubbock, TXLubbock, TX 3.233.23Bismarck, NDBismarck, ND 3.173.17Salt Lake City, UTSalt Lake City, UT 2.912.91Baltimore, MDBaltimore, MD 2.812.81St. Paul, MNSt. Paul, MN 2.792.79Minneapolis, MNMinneapolis, MN 2.572.57Seattle, WASeattle, WA 2.542.54Washington, DCWashington, DC 2.412.41Richmond, VARichmond, VA 2.252.25Portland, MEPortland, ME 1.971.97Wilmington, DEWilmington, DE 1.851.85Hartford, CTHartford, CT 1.631.63Worcester, MAWorcester, MA 1.631.63Bangor, MEBangor, ME 1.481.48Baton Rouge, LABaton Rouge, LA 1.451.45White Plains, NYWhite Plains, NY 1.371.37Providence, RIProvidence, RI 1.361.36Burlington, VTBurlington, VT 1.241.24Lebanon, NHLebanon, NH 1.171.17Manhattan, NYManhattan, NY 1.001.00

Preventive SurgeryPreventive Surgery

ConditionCondition Treatment Treatment OptionsOptions

• Silent gall stonesSilent gall stones Surgery versus watchful Surgery versus watchful waitingwaiting

• Chronic stable angina PCI vs CABG vs other Chronic stable angina PCI vs CABG vs other methodsmethods

• Carotid artery stenosis Endarterectomy vs Carotid artery stenosis Endarterectomy vs drugsdrugs

• Herniated discHerniated disc Back surgery vs other Back surgery vs other strategies strategies

• Early prostate cancer Surgery vs radiation vs Early prostate cancer Surgery vs radiation vs waitingwaiting

• Enlarged prostate (BPH) Surgery vs other Enlarged prostate (BPH) Surgery vs other strategies strategies

Which rate is right? Impact of improved Which rate is right? Impact of improved decision quality on surgery rates: BPHdecision quality on surgery rates: BPH

Knowledge of relevant treatment

options and outcomes

Concordance between patient values

and care received

Source: John E. Wennberg

Bottom Line Implications: Bottom Line Implications:

1. Clinical appropriateness should 1. Clinical appropriateness should be based on sound evaluation of be based on sound evaluation of treatment options (comparative treatment options (comparative effectiveness and outcomes effectiveness and outcomes research)research)

2. Medical necessity should be 2. Medical necessity should be based on Informed Patient Choice based on Informed Patient Choice among clinically appropriate among clinically appropriate options -- options -- high quality shared high quality shared decision-makingdecision-making

63%12%

25%

Preference Sensitive Care

Effective Care

Supply Sensitive Care

Proportion of Medicare Spending Attributed to Proportion of Medicare Spending Attributed to Each Category of Unwarranted VariationEach Category of Unwarranted Variation

Source: John E. Wennberg and Dartmouth Atlas

We’re wasting $600 – 800 We’re wasting $600 – 800 BILLION annually on BILLION annually on

unnecessary careunnecessary care

Part of the solution requires Part of the solution requires rethinking prevention and rethinking prevention and clinical decision makingclinical decision making

THE HEALTH CARE TRAIN THE HEALTH CARE TRAIN WRECKWRECK